To many, the insurance industry is a vast unknown that is supposed to respond when policyholders have an emergency or catastrophe, but beyond that, the details tend to get a little fuzzy.

In reality, while the insurance industry is a complex entity comprising insurance companies and their claims adjusters and managers, brokers, agents, risk managers, actuaries and more, they receive a great deal of support from a host of vendors such as third-party administrators, restoration contractors, software developers, researchers and others.

While not traditionally known as a swift-moving industry that embraces change easily, insurance companies do recognize the need to adopt new technology and partner with innovative companies that are technologically savvy, understand what policyholders need and complement what insurers have to offer.

One of those partners is Sedgwick Claims Management Services, Inc., a global provider of technology-enabled risk and benefits solutions that works with insurers to manage a wide variety of claims for more than 2 million people annually.

Innovating for the future

The winner of the 2017 Trailblazer Award, sponsored by Claims magazine, America's Claims Event and LexisNexis Risk Solutions, Sedgwick was recognized for its innovation in how it flags and handles workers' compensation claims through its decision optimization platform.

Sedgwick created and implemented a business model that uses its data to identify workers' compensation claims that could exceed $50,000 in total incurred costs, allowing the claims team to focus on specific areas or apply the resources necessary to ensure the best experience for an employee.

The company also generated a model to identify claims that could reach the $100,000 mark, giving the claims unit time to triage complex claims before the impact to outcome becomes severe. In addition, Sedgwick utilizes nurse resources in workers' compensation claims to significantly impact an injured employee's overall outcome. The results have been impressive for clients and claimants alike.

“Using our decision optimization platform, Sedgwick is able to do more than just reveal meaningful trends in claims data,” explained Sedgwick Group President, Bob Peterson. “We use our data to offer industry perspective and guidance, prescribe and automate the next steps to be taken on a claim and direct resources appropriately for exceptional care and service.”

Bob Peterson of Sedgwick (left) receives the Trailblazer Award from Frank Cesario of LexisNexis. (Photo: Daniel Gray Photography)

The impact of technology on claims

Technology is influencing the insurance industry from mobile applications that allow policyholders to report and follow claims to the information insurers can provide when a catastrophe arises. For workers' compensation claims, mobile technology provides a conduit for communicating with injured employees to ensure they are receiving the best care and critical information as they need it.

“With the ubiquity of smartphones, tablets and mobile devices, injured workers are now empowered in the claims process,” commented Peterson.” They have the ability to check the status of their claim and payment information in real time using self-service applications and can even report their own claims.”

Peterson added that injured workers can also use their mobile devices to receive medication or physician appointment reminders, schedule appointments, receive text messages with critical information or even chat with claims examiners and nurse case managers. “Injured employees can also send important documents and photos to their claims professionals…and can sign up for direct deposit through mobile applications. These technologies foster a more customized and immediate access experience for injured workers during what can be an unsettling and stressful time.”

Technology also plays an important role in how Sedgwick streamlines the claims administration process because it allows resources to be focused on the injured workers, such as using automated correspondence for routine communications so claims examiners have more time to address issues affecting the claims process. The use of rules engines also expedites the workflow so information is sent when needed.

Meeting workers where they are

As any employer knows, employees are critical to their organization's success and getting injured workers the care they need as soon as possible is in everyone's best interest. In addition, returning employees to the workforce reduces claims costs for insurers and employers, and has a positive effect in the healing process for the injured worker. Sedgwick has made a number of advancements in this area that are having a significant impact on how workers' comp claims are resolved.

The company is using technology to provide immediate information to patients through their smartphones, tablets and other mobile devices. “They have the ability to check the status of their claim and payment information in real time using self-service applications,” shared Peterson.

While treatment is important, pain management after an injury is also a consideration, especially given the addiction issues associated with opioids, narcotics and other strong prescription medications. “We are working with employers to explore alternatives to pain management and employing such tools as physician-patient contracts, pain management coaching partnerships, increased use of behavioral specialists or physical therapy,” reported Peterson.

ACE Awards recognizing industry excellence. (Photo: Daniel Gray Photography)

Many factors affect claims costs, but complex claims can have long-ranging effects for the employee and drive up costs significantly. Recognizing these factors, Sedgwick sees the value of creating plans that provide assistance to those impacted. “Employee advocacy should drive the formulation of these plans,” advised Peterson. “Communication should answer questions and provide reassurance. Pain management plans should be structured to meet employee needs without unnecessary or long-term reliance on opioids…An optimal recovery plan demands a holistic approach.”

Balancing act

For vendors working with insurers and their policyholders, the challenge arises in satisfying the different goals and wishes of each party. Peterson is proud of how the company balances the policyholder's needs against the realities of the policy while meeting the insurer's objectives.

“Every year, more than 15,000 Sedgwick colleagues take care of the needs of more than 2.6 million people who had something unexpected happen,” said Peterson. “Whether they have a workplace injury, need time away for the birth of a child, experience a medical situation that will lead to time off, are in an auto accident or suffer property damage, we are here to let them know that it's going to be ok. Our approach to providing quality services goes far beyond just managing claims – we strive to remove the complexity from the process by making it easy and effective for everyone involved.”

Not content to rest on their proverbial laurels, Sedgwick has set an aggressive agenda for 2018 with a focus on several areas including: compounding global risks, the shifting tide of policy, methods to bridge existing gaps, leveraging interdisciplinary care and ways to improve the customer experience through technology.

“Sedgwick is continually looking for ways to better serve our clients. As their needs evolve, our service strategies morph with them,” added Peterson. “Many of our offerings today stem from unique solutions developed in response to client challenges or requests. With the knowledge and support of Sedgwick's colleagues and our robust services offerings, we are well positioned to respond quickly and effectively to client needs in the early stages of development.”

Patricia L. Harman (pharman@alm.com) is editor-in-chief of Claims magazine.

Do you know a company or individual that provides outstanding customer service or innovation in the insurance industry?

Claims is accepting nominations for the Trailblazer Award, Claims Luminary of the Year and Customer Champion Award. Visit www.americasclaimsevent.com for more details. Deadline is May 1.

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Blazing a trail of innovation in the insurance industry

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